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Forum: Never say die – Why are doctors so reluctant to admit defeat?

By DONALD GOULD

WHY are so many doctors so bad at dealing with death? Dying, after all,
is the one ‘pathological’ condition which every one of us is certain to
experience sooner or later, and for that reason alone you might think that
the highly experienced and intelligent men and women who run our medical
schools would make absolutely sure that their pupils were sent into the
world knowing all that could be taught about the way to handle this inevitable
happening – how to deal with the mortally ill, and, just as importantly,
how to deal with their dear ones.

It is not so. Perhaps because the teachers don’t know what to teach,
and are just as inept in the matter as their apprentices.

Indeed, I suspect that neophyte physicians may often be more sensible
and sensitive at the death bed than their elders in the trade, and that,
somehow, increasing seniority and status increases the embarrassment felt
in the presence of the grim reaper.

Half-a-century ago, when, as a medical student, I was doing my ‘finals’,
I was asked to examine a young man with a huge swelling in his thigh. It
wasn’t a very difficult test and I easily and correctly guessed that he
was suffering from an advanced osteogenic sarcoma with secondary growths
elsewhere. Maybe I was a bit too pat and cocky with my answer. Anyway, I
had clearly irritated my inquisitor by a too glib response to his conundrum,
and he then asked me for the prognosis. ‘Hopeless,’ I said, which by any
sort of clinical reckoning must have been the right answer.

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But that gave him his chance. Towering above me he thundered: ‘You must
never say ‘hopeless’. You will never make a doctor if you ever use the word
‘hopeless’.’

I suppose that, in a philosophical sense, he may have been right. But
I don’t believe he was speaking as a philosopher. I think he was speaking
as a senior surgeon who couldn’t accept the idea that sometimes his special
skills might be useless and irrelevant to the needs of patients sent to
him for help.

Some years ago I talked to a young hospital house officer about his
work. ‘And it’s my job to talk to the relatives,’ he said, ‘and tell them
what’s happening. But a far worse job is talking to dying patients. On the
whole the doctors on this unit don’t tell dying patients the truth. If your
boss has said something vague or comforting, even if he knows a person’s
going to die, you can’t just go along later and contradict him. That would
raise dreadful torturing doubts. Sometimes I do tell a mortally ill patient
what to expect. I do it quickly before anybody else has had a chance to
tell a different story. And then I tell my bosses what I’ve said. But you
should be able to spend a proper time on this sort of talk. For God’s sake
– isn’t a dying person at least entitled to half an hour of his doctor’s
time each day? But I can’t find it for them. In any case, this ought to
be the consultant’s task. He’s the chap who’s supposed to have the experience
and understanding. He’s the chap who can best inspire confidence. And will
he do it? Will he hell!’

Just before Christmas I heard a very similar tale, this time from a
final-year medical student. ‘Even now, when the quality of life is supposed
to be important, I’ve seen women riddled with breast cancer who have no
chest left . . . and you’re piling in chemotherapeutic agents and telling
them ‘Maybe you’ll get better’ when they’re obviously on the verge of death.

‘We had a patient just like that, and I felt that what she needed was
to be told ‘You’re going to die’, so that she could come to terms with it,
and tell her young family what was going on, and say goodbye to her husband
and children. But they said, ‘No. We’ll give you another course of therapy.’
I argued with the consultant afterwards and he was very angry with me and
said, ‘If you look at the statistics you’ll find that one in a thousand
patients in this condition will pull through with the drug, so I can’t tell
her she’s bound to die.’ She was dead the following morning, and hadn’t
been given the opportunity to come to terms with what was happening to her.’

So nothing much has changed in 50 years. But why are so many clever
and experienced doctors apparently so reluctant to deal honestly and humanely
with their dying patients? I can’t believe it’s a matter of shyness and
embarrassment or an inborn lack of empathy, because my two young friends,
who might be expected to feel far less sure of themselves than their battle-hardened
superiors, not only had the empathy needed to tell them what should be done,
but also the courage to go ahead and do it.

I suspect that, having achieved eminence, the experts are unwilling
to admit helplessness and defeat, and cannot bear to remain inactive when
some remedy, however umpromising or inappropriate, can be essayed, and that
they need to recover a youthful innocence and vision, so that they treat
their patients as people, and not simply as the vehicles of disease.